U.S. individual om; FFSS. Use only -- .Dc.nu_tradte.or.stapIeJn_th1s space.-- . For the year Jan. 1-Dec. 31. 2012. or other tax year beginning ,2012, ending I .25 See Separate ;nS'tructiOnS_ Your first name and initial Last "am Your social security number BARACK .. OBAMA 11 a joint return, spouse's first name and initial Last name - Spouse's social secures number MICHELLE . OBAMA Home address (number and street). It you have a P.0. nox, see instructions. Apt. no. Make W, me 1 6 0 AVENUE NW . 5? City, town or post oflice, state, and ZIP code. It you have a foreign address, also complete spaces below. DC 30500 Foreign country name Foreign provinceistateiceunty Foreign postal code You Spouse Finn Status 'i L_i Single 4 ifi Head of household (with qualifying person). lithe 9 2 Married filing jointly (even it only one had income) person is a child but not your dependent, enter this child's 3 I: Married filing separately. Enter spoLise's SSN above name here. Gheck onty one box. . and full name here. 5 Ci Qualifying widowteri with dependent child . Ba LXJ Yourself. if someone can claim you as a dependent, do not check box Ba 2 Exemptions Ir Spouse . - on cw o: Dependents: - (21 Dependents social . W, 2 First name Last name number yo" . did not with you due to divorce MAL IA A OBAMA DAUGHTER It more than four NATASHA OBAMA DAUGHTER dependents, see Dafefiffin?s 5? instructions and 3 We check item I: cl Total number of exemptions claimed .. 4 mcome 7 Waoes. saiaries. tips, etc. Attach WTaxahleinierest Attach Schedulesiireouireu 8a 3.1 . 452 - Tax-exeinptintarest. Do not include on line 8a I Bi: I Attach Formisi w_2 hm. A550 Ordinary dividencls.Atiach Schedule it required 9a 2 . - aeacnrorms .. I 9b I Taxablereiunds, credits,or offsets oistate and local income was wm,i.em_ ii Nim9l?Y 11 12 Business income or (loss). Attach Schedule or (3-Capital gain or (loss). Attach Schedule it required. if not required, check here no-2, 14 other pains or (losses). Attach Form 4?9? .. 14 see instructions. 15a IRA distributions 15a liiaxabte amount 15b 16a Pensions and annuities 163 lJTaxa|Jle amount tea 17 Rental real estate, royalties, partnerships, corporations, trusts, etc. Attach Schedule 1? 5" do 18 Farm income or (loss). Attach Schedule 18 not attach, any payment, N50, 19 Un0ml3|0Ym3m3Dmpen3ati?n 19 please use 203 Sociatsecurtty benefits Qua . i ii Taxabie amount 20!: 1040'" 21 Other income. List type and amount 21 22 Combine the amounts in the tar right cotumn for lines through 21. This is your iotai income .. Eriucaiorexpenses 23 'Adjusted 24 2-: Gross 25 Health savings account ueduction.Attach Form 8889 25 income 26 Moving exper2ses.Atrach Eorrn 3903 26 2? part or seliernploymerittax. Attach Schedule Selt~employed SEP, SIMPLE, and oualitied plans 23 5 0 0 . 29 Self-employed health Insurance deduction 29 30 Penalty on early withdrawal or savings 30 31a Alimony paid ii Recipients SSN hr 31a 33 03000009 33 33 Student loan interest deduction 33 34 TUMOR andiees-M339" 3917 34 35 Domestic production activities deduction. Attach Form 8903 35 as 36 53.465- 37 Subtract tine 35 from tine 22. This is your adjusted gross income .. 3? 508 611 . LHA i=or Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. - Form 1046 r2o12} Form1040i2012) BARACK H. MICHELLE L. OBAMA Pane? Tax and 38 Amount from iine 37 (adjusted gross income) 38 608, 511 . ""'Gredit5"" Yofi I3 Tom] bgxe3-- -- -- - Standard - ii: Spouse was born before January 2, 1943, I: Blind. checked 393 in If your spouse Iternizes on aseparate return or you wereaduai-status alien, check here 35th - 40 Itemized deductions (from Schedule A) eryour standard deduction (see left marginSubtract line 40 from line 38 41 350 226 . 42 Exemptions. number on line Br! 42 15 . 200 - -ta Taxable income, Subtract line 42 from tine 41. itline 42 is more than -Tax. Checktianyirorn: aI:] Forrn(s)B814 Form 4972 cm 952 election 44 87 455 - -15 Alternative minimum tax. Attach Form 6251 .. Add |ines44and45 46 108. 686 - gaagnaigiafiino Foreign tax credit. Attach Form 1116 if required 4? 3 402 . $5,050 43 Credltfor child and dependent care expenses. Attach Form 2441 48 Igmfirfitinu 49 Education credits from Form 3863, line t9 49 Ouaflhrino 50 Retirement savings uttons credit. Attach Form 3880 50 51 Child tax credit. 8312, itreouired 51 Egjgagzld 52 Ftesidentiaieneray credits. Attach Form 5595 52 $3,700 . 53 Other oreditstrorn Form: I: 3800 I: 8301 I: 53 54 Add iine's47thrDuch 53-These arevouriotal credits 54 3 I 402 - 55 Subtract {inc 54 from tine 45. It line 54 is more than line 46, enter -other 55 Sfiif-empioymfinttax-Aitaflii Scheduie Taxes 57 unreported soclai security and Medicaretaxirorn Form: a I: 413? 11:] 8919 57 58 Additionai tax on tFtAs, other qualified retirement plans, etc. Attach Form 5329 it required 58 59a Household emoioymenttaxes from Scheduieit 59a First-time homebuyer credit repayment Attach Form 5485 if required 59b 60 other taxes. Enter code(s)irorn instructions 80 a1 Add lines 55 through BiJ.This isyourtotaitax 61 112 . 214 Payments 62 Federal income tax withheld Forms and 1099 B2 99 . 514 . 63 2012 estimated tax payments and amount appiied from 2011 return 64a Earned income crodit{EiG) B43 ch??d.at1aci1 ttontaxabie oombatpay election I I as Additional child tax credit Attach Schedule 3312 as 66 American opportunity credit from Form 8353, tine 8 68 3? 5? 68 Amount paid with requestfor extension to file 68 B9 Excess 69 YD Credit tortederaitaxon fuels. Attach Form 4136 ID Credigs from Form: 3 E2439 d[:I3335 71 . 72 Add lines s2, 33, sea, and so through 71.These are your total payments 72 129 . 029 . Refund ti tine 72 is more than tine 61, subtract line 81 from line 72. This is the amount you 13 1 5 3 15 . Dam Ha?gountoiline 73 ouwant refunded to you. IfForrn 8833 is attashedflohect here 74: hacmbl;? Type: cheating Savlnus Pd nfi?r1?t?crI 1'5 Amount of line ?3you want applied to your 2013 estimated tax .. Amount ?6 Amount you owe. Subtract line 72trorn line 51. For details on howto pauses instructions 76 5 YOU Owe Estimated tax penatty{see instructions) 77 I ?if'i'fn amaacireas CHI cacao. IL 50601 Thirfi Part-Y Do you want to attain another person to discuss this return with the tits (see instructions)? IE Yes. Complete below. I: No Desrcnee SOLI-IEIM I Sign Under use-tare that I have axarnlned this return and accompanying schaduies and statements. and to the best of my knowicdga and belief, they are true, can i preparer [other than taxpayer) is based on at} information or which preparer has any knowledge. Here ralonat Dela Youroocu anon Daytime phone number I3 'ffiil 2013 Us PRESIDENT 3p :95? 3 0 a-'5 5 nature. If joint rel . I11 at Data Spouse's occupation 11 the IRS sent you an Identity Dr Protaolion PIN. records>> We 3113 US FIRST LADY enemas I I Preparers signature' Data Check I: if salt-employed Preparer MICHAEL SOLHEIM 5/23 Use Oniy SOLI-IEIM HOWELL seam, PC 130 _1\r LASALLE so, see 22oo . Underpayment of Estimated Tax by 1 OMB. Form . . .. . . 5 information about Form 2210 and its separate instructions is at . Department of the Treasury Aflachmem ifiiaifiai 39i'Vi?? -5 Attach to Form 1040, 1040A, 1040NR, or 1041. Sequence No. 05 Narnels) shown on tax return I identifying number BARACK . E: MICHELLE . OBAMA Do You Have To File Form 2210? Complete lines 1 through 7 below. is line 7 less than $1 ,000? I39 not file Form 2210, You do not owe a p3napy_ No Complete lines 8 and 9 below. Is line 6 equal to or more thanpenalty. Do not file Form 2210 line 9? (but if box in Part It applies, you must file page 1 of Form 2210). No You may owe a penaity. Does any box in Part it below appiy? lip Dou must file Form 2210. Does box B, C, or in Part it apply? No Yes N0 I You must figure your penalty. I Do not fiie Form 2210. You are not required to figure your You are not required to figure your penaity because the IRS wili penalty because the IRS figure it and send you a bill for any figure it and send you a bill for any unpaid amount. If you want to unpaid amount. if you want to figure it, you may use Part or figure it, you may use Part Ill or Part as a worksheet and enter Part IV as a worksheet and enter your penalty amount on your tax your penalty amount on your tax return. but file only page 1 of return, but do not file Form 2210. Form 2210. . Part i Required Annual Payment 1 Enter your 2012 tax aiter credits from Form 1040, line 55 (see instructions if Form 1040Othertaxes. including seiimnioymeniiax (966 instructionscredits (988 3 )1 4 Current year tax. Combine lines 1, 2, and 3. it less than $1,000, stop; you do not owe a penalty. Do not iite Form 2210 .. Multiply ans 4 by 90% reel Withholding taxes. Do not include estimated tax payments (see instructionsSubtract line from tine 4. ll tees than $1,000, stop; you do not owe a penalty. Do notilie Form 2210 Maximum required annuai payment based on prior year's tax {see instructionsRequired annual payment. Enter the smalleroflinefiorlinefi 9 100 993 . Next: is tine 9 more than line penalty. Do notflle Form 2210 uniess box below applies. El Yes. You may owe a penalty, but do not file Form 2210 unless one or more boxes in Part 1] beiow appliesapplies, you must figure your penalty and file Form 2210. 0 ii box Aer applies {but not B, 0, or 0) file only page 1 of Form 2210. You are notrequired to figure your penalty; the IRS will figure it and send you a bid for any unpaid amount. it you want to figure your penalty, you may use Part or IV as a worksheet and enter your penalty on your tax return, but tile oniypage 3 of Form 2210. Part Reasons for Filing. Check applicable boxes. if none apply, do not file Form 2210. A l__l You request a waiver (see instructions) of your entire penalty. You rnustcheck this box and tile page 1 of Form 2210, but you are not required to figure your penalty. - I: You request a waiver (see instructions) of pan of your penatty. You must figure your penalty and waiver amount and file Form 2210. 0 :1 Your income varied during the year and your penalty is reduced or eliminated when figured using the annualized Income inslaliment method. You must figure the penatty using Sctieduie Al and file Form 2210. I: Your penalty is lower when figured by treating the federal income tax withheld from your income as paid on the dates it was actuaily withheld, instead of in equai amounts on tt1e_payment due dates. You must iipure your penalty and iite Form 2210. :1 You iited or are filing a Joint return for either 2011 or 2012, but not for both years, and line 8 above is smailer than line 5 above. You must tile page 1 of Form 2210, but you are not required to figure your penalty (unless box B, 0, or 0 applies). LHA For Paperwork Reduction Act Notice, see separate instructions. Form 2210 (2012) Form2210(2012} BARACK H. 8.: MICHELLE L. OBAMA . [Part IV ifyou'are sting Eormto-,40NR Page :3 Section A - Figure Your Underpayment PawnentDueDams' to 4/15:12 (M e!15x12 9n5n2 (M mans 13 20 25 26 Required installments. It box 6 In Part II applies, enter the amounts from Schedule At, line 25. Otherwise, enter 25% (.25) of line 9, Form 2210, in each column 25,248. 25,248. 25,248. 25,249. Estimated tax paid and tax withheld. For coiumn only, also enter the amount from line 19 on Fine 23. line 19 is equal to or more than line 13 tor at! payment periods, stop here: you do not owe a penatty. Do not tile Form 2210 unless you checked at box in Part 49,394. 24,879. 29,879. 24,877. Complete lines 20 through 26 of one cofumn before going to tine 20 of the next column. Enter the amount, it any, from line 25 in the previous cotumn 24,146. 23,777. 28,408. 49,025. 53,656. 53,285. Add the amounts on tines 24 and 25 In the previous column Subtract line 22 from tine 21. it zero or less, enter For column (3) onty, enter the amount from line 19 49,394. 49,025. 53,656. 53,285. It the 23 is zero, subtract line 21 trom line 22. 91heFWi9e.enTBr-0- Unclerpayment. It line 18 is equal to or more than line 23, subtract line 231rorn line 18. Then go to line 20 of the next column. Otherwise, go to time 26 5* 25 Overpayment. It line 23 is more than time subtract line 'l8 from tine 23. Then go to line 20 of the next column 25 24,146. 23,777. 28,408. Section - Figure the Penalty (Use the Worksheet for Form 2210, Part IV, Section Figure the Penalty in the instructions.) Penalty. Enter the totai penalty from line 14 of the Worksheet for Form 2210, Part W, Section 8 Figure the Penalty. Also include this amount on Form 1040, line 77; Form 104021, line 46; Form line 74; Form 1040118-E2, tine 28; or Form 1041, tine 26. Do not tite Form 2210 untess you checked a box in Part II 2? DC 212491 U144-13 Form 2210(2012) SCHEDULE A . .- (Form. . itemized Deductions separate OMB No. 1545-0074 (99) Attach to Form 1040.. _Name{s) shown on Form 1040 Your social security number BARACK H. E: MICHELLE . . Medical Caution. Do not include expenses reimbursed or paid by others. and i 1 Medicai and dental expenses (see instructions) 1 Dental 2 Enter amount from Form 1040, line 33 i 2 I Expenses 3 Muitipiy tine 2 by 7.5% (.075) 3 4 Subtract line 3 from line if iine 3 is more than line 1, enter -0- .. i 4 Taxes You 5 State and tocei (check only one box): Paid a Inoome taxesi:i Genera! sales taxes 6 Heat estate taxes (see instructionsPersona? PFOPBTW Taxes .. 7 8 Other taxes. List type and amount .. 3 9 Adcnines sthrougha .. J9 63 305- interest 10 Home mortgage interest and points reported to you on Fonn 1098 You Paid '11 Home mortgage interest not reported to you on Form 1098. it paid to the person from whom you bought the home, see instructions and show that person's name, identifying no., and address Note>> 11 Eggfiegodgage 12 Points not reported to you on Form 1098. See instructions for special ruies 12 deduction may 13 Mortgage insurance premiums (see instructions) 13 P3 |'mm?d (339 14 Investment interest. Attach Form 4952 it required. {See instructionsAdd lines 10 through 14 .. I 15 I - Gifts to 16 Gifts by cash or check. If you made any gift of $250 or more, see instmotions STMT 3 Charity Other than by cash or check. if any gift of $250 or more, see instructions. if YOU made 3 You must attach Form 8283 if over $500 17 gift and got a 18 . 18 beneffl for mm prior year .. see instructions. 19 Add lines 16 through Casualty and Theft M35595 20 Casualty or theft Iossfes). Attach Form 4684. {See instructions.) 20 Job Expenses 21 Unreirnbursed employee expenses - iob travel, union dues, job education, etc. and Certain Attach Form 2106 or 2106-EZ if required. {See instructions.) Miscellaneous Deductions -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- 21 22 Tax P"eP3i'3'fi0" 7933 22 23 Other expenses - investment, safe deposit box, etc. List type and amount 23 24 Add tines 21 through 23 24 25 Enter amount from Form 1040, line 38 25 by 2% (-02) 25 27 Subtract line 26 from line 24. It line 26 is more than line 24. enter -0- 27 Other 28 Other - from list in instructions. List type and amount Miscellaneous Deductions -- Fr 28 Totai 29 Add the amounts in the far right coiumn for Zines 4 through 28. Aiso, enter this amount on Form 1040, Itemized line -DedUCt|0n5 30 If you eiect to itemize deductions even though they are less than your standard deduction, check here ..2 .. i: LHA 319591 01-11-33 For Paperwork Reduction Act Notice, see Forrn instructions. eciuie A {Form 1040} 2012 SCHEDULE - (Form-1040A--or~1040) - Department oi the Treasu Internal Revenue Service Interest and Ordinary Dividends 'c.raE2;o; I991 or information aimuisciieduie [Form 1040A or 1040) and its instructions is at ,9 . Attach OMB No. 1545-DDT4 rnent Sequence No. 03 Narne{s}si1own on return our sociai security number BARACK . Sc MICHELLE . OBAMA Part I 1 List name of payer. If any interest is from a seller-financed mortgage and the buyer used the Amwnt lnterefi property as a personal residence, see instructions and iist this interest iirst. Aiso, show that buyer's social security number and address it- BOND PREMIUM AMORTIZATION -3 5 08 . JP MORGAN 4 4 . NORTHERN TRUST SECURITIES US GOVT INTEREST 16 3 48 . Note, ifyou . NORTHERN TRUST SECURITIES US GOVT INTEREST PAID -1 422 . received a Form 1099-INT, Form 1099-Oi D, 1 or substitute statement from a brokerage firm, iist the firm's name as the payer and enter the total interest shown on that form. 2 Add the amounts on lanai 2 11:4 5 2- 3 Excludabie interest on series EE and i U.S. savings bonds issued after 1989. Attach Form 8815 3 4 Subtract iine 3 from line 2. Enter the resuit here and on Form 1040A. or Form 1040, iine Note. it line 4 is over $1,500, you must cornpiete Part Amount Part ii 5 List name of payer Ordinary NORTHERN TRUST SECURITIES 2 . Dividends Note. if you received a Form 1099-Div or substitute statement from a brokerage firm, 5 iist the firrn's name as the payer and enter the ordinary dividends shown on that form. 6 Add the amounts on iine 5. Enter the totai here and on Form 1040A, or Form 1040, iine 9a . 6 2 - Note. if line 6 is over $1,500, you must complete Part Part You must complete this part if you had over $1,500 of taxable interest or ordinary dividends; {bi had a foreign Yes ND F0l'eiQfI account; or [oi received a distribution from, or were a grantor of, or a transieror to, a foreign trust. ACCOUNTS 7a At any time during 2012, did you have a financiai interest in or signature authority over a financial account (such and as a bank account, securities account, or brokerage account} located in a foreign country? See instructions if "Yes," are you requiredto Form TD to report that financial interest or signature authority? See Fonn TD 9022.1 and its instructions for filing requirements and exceptions to those requirements It you are required to file Form TD Q0-22.1, enter the name of the foreign country where the iinanciai account is located .. 227501 8 During 2012, did you receive a distribution from, or were you the grantor oi, or transferor to, a foreign trust? 09-25-12 if Wes," you may have to file Form 3520. See instructions .. For Paperwork Reduction Act Notice, see separate instructions. Schedule 1040A or 1040} 2012 BARACK H. OBAMA SCHEDULE 0 Profit or Loss From Business . (E_0_r_m .1 0410) . . pepanmem 0, ma b~ For iaiorrnaiion on Scbeduie and its instructions, go to Attachment Intamaifievenue Service (991 Attach to Form 10411, 10403111, or 1041; partnerships peneraily rnustiile Form 1065. Sequence No.09 Name of proprietor Social security number (sen) A Principal business or profession, inctuding product or service (see instructions) AUTHOR 3 Enter code from instructions 711510 Business name. lino separate business name, leave blank. BARACK . OBAMA Emptoyer ID number {see Instr.) Business address {including suite or room no.) City, town or post office, state, and code Accounting method: (1) Ill Cash (2) l__l Accrual (3) l_l Other(speciiy) 6 Did you "materialiy participate" in the operation of this business during 2012? it see instructions for Eirnit on losses Yes [3 No iixou started oracouiredthis business during 2012. check here M: 1 Did you make any payments in 2012 that would require you to file Forms) 1399? (see instructions) I: Yes Kl No lt"Yes," did you or wili you tiie rettuired Forms 1099? .. Yes I: No I Part I I Income - 1 Gross receipts or sales. See instructions for line 1 and check the box if this income was reported to you on Form W-2 - and the "Statutory employee" box on thatform was checked El 1 2 Returns and allowances (see instructions) 2 3 5uhtract|ine2 irorn Iinei 3 4 Gostoi coeds sold (from line 42} 4 5 5 6 other income, including ferierat and state gasoiine or fuel tax credit or refund {see instructionsGross income. Add lines Part II I Expenses Enter expenses for business use of your home only on line 30. 3 8 13 Office 13 519 9 Car and truck expenses 19 Pension and profit-sharing plans 19 (see instructions) 9 211 Rector lease (see instructions): 1D Commissions and fees 14 4 4 8 . Vehtcies, machinery, and equipment 20a 11 Contract labor {see 11 Other business property 20b 12 Deplefififl . . 21 331031153" 21 13 Depreciation and section We 22 Suppiies (not included in Part Iii) 22 expense deduction (not ?nctuded in - 23 Taxes and licenses 23 Part ill) {see instructions) 13' 24 Trayet, meats, and entertainment 14 Employee benefit programs (other Travei 242 than on fine 19) 14 Deductible meals and 15 Insurance (other than health) 15 entertainment (see instructions) 24b 15 interest: 25 Utilities 35 a Mortgage (paid to banks, etc-) 16a 26 Wages (less employment credits) 23 Other 1612 2? a Otherexoeosasiirom line 48) 27a 1? Legal and professional services .. 1? ti Reserved iortuture use .. 27b 28 Total expenses before expenses for business use oihome. Add lines 8 through 273 -Tentative rt-wilt or (loss) Subtract tine 23 item tine .. Expenses ior business use of your home. Attach Form 3829. Do not report such expenses elsewhere 30 31 list profit or (loss). Subtract iine 30 from line 29. up if a profit, enter on both Form 1040, tine 12 (or Form line 13) and on Schedule SE, tine 2. (it you checked the box on line 1, see instructions). Estates and trusts, enter on Form 1341, line loss, you must go to line 32. 32 If you have a loss, check the box that describes your investment in this activtty (see Instructions). a If you checked 32a, enter the loss on both Form 1040, ilne 12, (or Form 1i}4EliliR, tine 13) and on Schedule SE, line 2. {if you checked the box on line 1, see the Fine 31 instructions). Estates and trusts, enter on Form 1041, line 3. Ii you checked 32h, you must attach Form 6198. Your loss may be limited. LHA For Paperwork Reduction Act Notice, see separate instructions. 220001 1 2-23 ~12 as 32b l:l Schedule 6 {Form 1040) 2012 . SCHEDULE Department of the Treasury internal Revenue Service information about So Capital Gains and Losses 'Bv Attach heduie and its separate instructions is at 0. >Use Form 8949 to list your transactions for lines 1, 2,3, 8, 9, and 10. OMB No. 1545-0074 Attachment Sequence No. 12 Namefisl shown on return BARACK . MICHELLE . OBAMA Short--Term Capital Gains and Losses - Assets Held One Year or Less Your social security number Cornpiete Form 8949 before completing line 1, 2, or 3. This form may be easier to complete if you round off Proceeds (sales price) from FDrn1(s} 3949, Part I. (B) Cost or other basis from 8949, Part I. Adjustments lo gain or loss trom Formls} 3949, Part 1. Gain or (loss) Subtract column irom column (ti) and combine the cents to whoie donarsi line 2, column Id) line 2, column line 2, column result with coiurnn 1 Short-term totals from all Forms 8949 with box A checked in Part I .. 2 Short-term totals from all Forms 8949 with boxBchecl> 535>> 10 Long~terrn totals from all Forms 8949 with box 0 checked in Part ii .. Gain from Form 4797, Part long-term gain from Forms 2439 and 6252; and ?ong~terrn gain or {loss} from FOIWS 4584. 6781. and 11 12 Net long-tenn gain or (loss) from partnerships, corporations, estates, and trusts from Scheduie{s) K-1 12 13 Capital gain disifibuflons 13 I 14 Long-term capital loss carryover. Enter the amount, if any, from line 13 of your Capital Loss carryover worksheet in the instructions 14 1 1 5 151-} 15 Net long-term capital gain or (loss). Combine lines 8 through 14 in column Then go to Partllionpage2 .-. .. 15 LHA For Paperwork Reduction Act Notice, see your tax return instructions. 220511 'i2-3'l~ Schedule (Form 1040} 2012 12-31-12 Schedule (Form 1040) 2012 BARACK . Sc MICHELLE IL . OBAMA :39, 2 Part ill I 16 Combine lines 7 and 15 and enter the resuit line 16 is again, enter the amount from line 16 on Form 1040, line 13, or Fotm line 14. Then go to iine 1? below. 0 If fine 16 is a loss, skip lines 1? through 20 below. Then go to line 21. Aiso be sure to complete line 22. 0 If iine 16 is zero, skip lines 17 through 21 below and enter -0- on Form 1040, line 13. or Form line 14. Then go to tine 22. 17 Are tines 15 and 16 both gains? Yes. (30 to line 18. No. Skip tines 18 through 21, and go to tine 22. 18 Enter the amount, if any, irom line 7 of the 28% Rate Gain Worksheet in the instructions 13 19 Enter the amount, if any, from line 18 of the Unreoaptured Section 1250 Gain Worksheet in the instructions 19 20 Are lines 18 and 19 both zero or biank? . Yes. Compiete the Qualified Dividends and Capital Gain Tax Worksheet in the instructions for Form 1040, line 44 (or in the instructions for Form 1040NR, line 42). Do not complete lines 21 and 22 below. i:l No. Complete the Schedule Tax Worksheet in the instructions. Do not cornpiete lines 21 and 22 beiow. 21 If ilne 16 is a loss, enter here and on Form 1040, line 13, or Form tine 14. the smaller of: The 5038 on tine manied filing separately, ($1,500) - Note. When figuring which amount is smaller, treat both amounts as positive numbers. 22 Do you have qualified dividends on Form line 9b, or Form ilne 101:? El Yes. Complete the Qualified Dividends and Capital Gain Taxworksheet in the instructions for Form -1 040, line 44 (or in the instruotions for Form 1040NR, line 42). No. Cornpiete the rest of 1040 or Form Schedule {Form 1040} 2012 220512 Sales and Other Dispositions of Capital Assets OMB Form 8949 . . . A Depmmem ?jthe'1'[eaSury Information about Form 8940 and its separate instructions is at 'WWw_;r3_g0vgfom35g49_ Machmem lntemai Revenue Service (99) Frie with your Schedule to for lines Schedule D. Sequence Narnets) shown on return Social security number or taxpayer identification no. BARACK H. E: MICHELLE L. OBAMA Most brokers issue their own substitute statement instead oi using Form 1039-8. They also may provide basis iniorrnation [usually your cost} to you on the statement even it it is not reported to the iFlS. Before you check _Box A, E, or 6 below, determine whether you received any statementtsi and. if so, the transactions for which basis was reported to the IRS. Brokers are required to report basis to the IRS for most stock you bought In 2011 or teter. Part i I 3h0l'iI'TB|'|Ti- Transactions invoiving capital assets you held one year or less are short~term. For tong-term transactions, see page 2. You must check Box A, B, or below. Check only one box. if more than one box applies for your short-term transactions, complete a separate Form 8949, page for each appilcabie box. it you have more shorbterrn transactions than wilt fit on this page for one or more of the boxes, cornpiete as many forms with the same box checked as you need. Shortterrn transactions reported on Form(s) 1099-B showing basis was reported to the iFiS (B) Short-term transactions reported on Forrnis) showing basis was not reported to the IRS Short-term transactions not ed to on Form 1099Description of property Date acquired Date sold or '30?t 01' Other in column (9 enter a code in 9055)>> 100 30- XYZ 00-} (M0-. W-) di5P'338d (Sagas price) hams' 559 the column comm" (9) . (Mow day] Note beiow and Column ((1)800 see Column the instructions combine the result Amount with column Codets) US TREASURY NOTE I 2 Totais.Acld the amounts in columns and negative amounts}. Enter each total here and include on your Schedule D, line 1 {if Box A above is checked), line 2 (ii Box above is or tine 3 Box above is 992,000. 992,000. 0. Note. if you checked Box A above but the basis reported to the IRS was incorrect, enter in column the basis as reported to the iFiS, and enter an adjustment in coiumn to correct the basis. See Column in the separate instructions for how to figure the amount of the adjustment. 223011 LHA For Paperwork Reduction Act Notice, see separate instructions. Form 3949 {2012} -Form 8949 Attachment Sequence No; Narne(s) shown on return. {Name and SSN or taxpayer identification no. not required if shown on other side.) -- Page2 Social security number or taxpayer identification no. BARACK H. 5. MICHELLE L. OBAMA Most brokers issue their own substitute statement instead oi using Form 1099-B. They siso may provide basis Intorrnation {usually your cost) to you on the statement even if It is not reported to the EH8. Beiore you check Box A, B, or 0 below, determine whether you received any statamenl{s) and. It so, the transactions tor which basis was reported to the IRS. Brokers are requtred to report basis to the tRS1or most stock you bought In 2011 or later. I Part ii I Long-Term. Transactions involving capitai assets you held more than one year are long term. For short--term transactions, see page You must check Box A, B, 0, 0 below. Check only one box. if more than one box applies for your long-term transactions, comptete a separate Form 8949, page 2, for each appiicable box. if you have more long-term transactions than will fit on this page for one or more of the boxes, cornptete as many forms with the same box checked as you need. (A) Long--term transactions reported on Form(s) 1099-B showing basis was reported to the R318 (13) Long-term transactions reported on Form(s) showing basis was not reported to the IRS term transactions not to on Form 1099-3 3 (C) (9) stment, any, 50 9 Dr (M Description of property Date acquired Date sold or Pmceeds C051 01' Other less' If you enter an amoum Gain 05' i33'93 Price) basis. See the Note below and see Coiurnn in the instructions Codeis) 1,015,365, tract column (3) column and combine the result with column (9) 5 I in column enter a code in (Example: 100 sh. XYZ Co.) day, yr.) disposed column (1) ea instructions, day, yr.) Amount of US TREASURY NOTE 1,016 out). 4 Totals. Add the amounts in columns and {subtra negative amounts). Enter each total here and include on your Schedule D, line 8 {if Box A above is checked), line 9 {if Box above is ortine10 Boxcabotre is 1.915.?99- 1.915.355 535- Note. if you checked Box A above but the basis reported to the IRS was incorrect, enter in column the basis as reported to the IRS, and enter an adjustment in column lg) to correct the basis. See Column in the separate instructions for how to figure the amount of the adjustment. 223012 Gt-02-13 Form 3949 (2012) Narneof personwith so-if-employment income (as shown on Form 1040) . - Schedule SE (Form 1040} 2012 Attachment sequence No. 1 7 Page 2 .. .. person with self--empioyrnent .. BARACK I-I . OBAMA Section - Long Scheduie SE Part I Self-Employment Tax Note. If your only income subject to is church employee income, see instructions. Also see for the definition of church employee income. A if you are a minister, member of a religious order, or Christian Science practitioner and you filed Form 4361, but you had $400 or more of other net eamings from seif-employment. check here and continue with Part 1 1 a Net farm profit or (loss) from Schedule F, line 34, and farm partnerships, Schedule K-1 (Form 1065), box 14, code A. Note. Skip lines 1a and 1b if you use the farm optional method (see instructions} 1a if you received sociai security retirement or disability benefits, enter the amount of Conservation Reserve Program payments included on Schedule F, line 4b, or listed on Scheduie K-1 (Form 1065), box 20, code 1b 2 Net profit or (loss) from Schedule 0, line 31; Schedule C-EZ, tine 3; Schedule K-1 {Form 1065), box 14, code A (other than farming); and Scheduie K-1 {Form 1005-B), box 9, code J1. Ministers and members of retigious orders, see instructions for types of income to report on this line. See instructions for other income to report. Note. Skip this line if you use the nonfarm optional method (see 2 25 7 7 2 a oomoineIines1a.1b.aro line Bis more than zero, multipiy line 3 by 92.35% (.9235). Otherwise, enter amount from iine Note. if line 4a is less than $400 due to Conservation Reserve Program payments on line 1b, see instructions. if you eiect one or both of the optional methods, enter the total of iines 15 and17 Combine lines 4a and 4b. If less than $400, stop; you do not owe self-employment tax. Exception. if Iess than $400 and you had church employee income, enter -0- and continue .. Enter your church employee income from Form W-2. See instructions for definition of church ernpioyee income 5a Multipiy iine 5a by 92.35% {.9235}. if less than $100, enter -0- 5b 6 Add lines Maximum amount of combined wages and self-employment eamings subject to social security tax or the 4.2% portion of the 5.65% railroad retirement (tier 1) tax for 2012 7 110,100.00 8 a Totai social security wages and tips {total of boxes 3 and 7 on Fcrm(s) W2) and railroad retirement (tier 1) compensation. it $110,100 or more, skip fines at>> through to. and go to line 11 Ba 11 0:1 0 0- Unreported tips subject to sociai security tax (from Form 4137, line 10) Elb Wages subject to social security tax (irom Form 8919, line 10) 8c Add "nos 33. 3b. and Bo 3d 9 Subtract tine Bd from line if zero or less, enter -0- here and on tine 10 and go to line 11 9 "0 MU|tiPiy the omolior of lino 5 or line 9 by 10-4% (-104) .. 10 11 Moltioiv ans 6 by2.o% (.o2oi 11 6 .. 93 0- 12 Self--ernployn1ent tax. Add lines 10 and 11. Enter here and on Form 1040, tine 56, or Form line Deduction for employer-equivalent portion of self-employment tax. Add the two foliowingamounts. 0 59.6% (.598) of line 10. - Onehaif of line 11. Enter the result here and on Form 1040, line 27, or Form 1040NR, line Part 1' Optional Methods To Figure Net Earnings (see instructions) Farm Optional Method. You may use this method only if is} your gross farm income' was not more than $6,780, or your net farm profits 2. were less than $4,894. 14 Maximum income forootionai methods 14 4:520-00 15 Enter the smaller of: twothirds (2:13) of gross farm income' (not iess than zero) or $4,520. Also include this amount on Zinc 413 above .. 15 Nonfarrn Optional Method. You may use this method only if your net noniarm profits 3 were fess than $4,894 and aiso less than 72.'i89% of your gross nonfarrn income, and you had net earnings from seii-employment of at least $400 in 2 of the prior 3 years. Caution. You may use this method no more than five times. 15 Subtract one 15from iino 14 15 17 Enter the srnalier of: two-thirds (216) of gross nonfarm income" (not iess than zero) or the amount on 15- Also inoluoo this amount on Fine 4b obovo .. 17 'From Sch. F, this 9, and Sci1.K-1 (Form 1055), box 14, code B. 3 From Sch. 0 fine 31; Sch. C-E2, time 3; Sch. l(~1 (Form 1055), box 14, cotton; 9 From Sch. F, iine 34, and Sch. K-1 (Form 106 box 14, code A - minus the and Sch. K-1 (Form 1065-8), box 9, code J1. amount you would have entered on time 1b had you not used the optional 4 From Sch. 0 line 7; Son. C-E2, time 1; Sch. i<-1 (Form 1065}, box 14, code 0; method. and Sch. K-1 (Form 1085-B), box 9, code J2. 224502 to-1e-12 Scheduie SE (Farm 1040) 2012 OMB No.1545-0121 1 Foreign Tax Credit . . - --.. - -- Depaflmam ("the Treasury Attach to Form 1040, 1040MB, 1041, or Attachment information about Form 1116 and its separate instructions Name Identifying number as shown on page 1 of your tax return BARACK . 8: MI CI-IELLE . OBAI-IA Use a separate Form 1116 for each category of Income iisted below. See Categories of income in the instructions. Check only one box on each Form 1116. Report ali amounts in U.S. doitars except where specified in Part II beiow. a I: Passive category income Section 901[i) income Lump-sum distributions is General category income It I: Certain income re-sourced by treaty Residentoi(nan1eotcountry}> UNITED STATES Note: if you paid taxes to only one foreign country or U. S. possession, use column A in Part! and line A in Part ii. if you paid taxes to mom than one foreign country or U.S. possession, use a separate coiumn and fine for each country or possession. Part I Taxable Income or Loss From Sources Outside the United States (for Category Checked Above) Foreign Country or US. Possession Total A (Add cols. A, B, and C.) 9 Enter the name of the foreign country or U.S. OTHER possession COUNTRIES 1a Gross income trom sources within country shown above and ot the type checked above: 39,875. 'ta 39,875. Check if line ta is compensation for personal services as an employee, your total compensation from ail sources is $250,000 or more, and you used an alternative basis to determine its source (see instructions) p. I: Deductions and losses (Caution: See instructionsPro rate share oi other deductions not definitely reiated: a Certain itemized deductions or standard deduction Other deductions (attach statement) Add iines Gross ioreion source income 3 9 3 7 5 Gross income from all sources Divide tine 3:1 by line Muitipiv|ine3cbyiine Pro rata share of interest expense: a Home mortgage Interest (use worksheet for Home Mortgage interest in the instructions) 2 .6 3 9 . Other interestexiiense 5 Losses trom torsion sources 6 Addlines2,3g,4a,4b,and5 .. 14:049- 5 14:049- 7 Subtract line 5 from line ta. Enier the result here and on tine 15, page Part II I Foreign Taxes Paid or Accrued 55 Giaimed Foreign taxes paid or accrued I for taxes (you mast . in foreign currency in U.S. dollars check one) other . IE Paid Taxes withheld at source on: Uglggigenr Taxes withheld at source on: {fzireign (fig)-gsagliafaidarfn 8 (5) Accrued taxes paid or taxes paid or accrued (add cols. U) (K) Dividends {ii Interest accrued Dividends figyatfilggd (Q) Interest accrued (03 Through Add tines A through 0, column Enterthe total here and on line 9, page LHA For Paperwork Reduction Act Notice, see instructions. Form 1115 (2812) Form 111e{2o12) BARACK H. s. MICHELLE L. OBAMA Paoea wart I .. - 9 Enter the amount from line B. These are your total ioreign taxes paid or accrued for the category of income checked above Part Carryback or carryover (attach detailed computation) 10 11 Addiines9and10 11 3 403 - 12 Reductioniniorelgntaxes 12 13 Taxes reclassified under high tax kiokout 13 14 Combine lines 11, 12, and 13. This is the total amount of foreign taxes available for credit .. Enter the amount from line 7. This is your taxahie income or (toss) from sources outside the United States {heiore adjustments) for the category of income checked above Part Adlusimeflls 10 fine 15 16 17 Combine the amounts on lines 15 and 16. This is your net foreign source taxable income. (tithe result is zero or less, you have no ioreign tax credit for the category of income you checked above Part 1. Skip lines 18 through 22. However, it you are more than one Form 1116. you must complete line 20lndividuatst Enter the amount from Form 1040, line 41, or Form 1D40i\iR, line 39. Estates and trusts: Enter your taxable income without the deduction ior your exemption 13 350 225 . Caution: if you figured your tax using the iower rates on queiified dividends or capitai gains, see instructions. 19 Divide line 17 by line 13. it this was more than tine 13, enter'1" 19 ?73741 20 individuals: Enter the amount from Form 1041}, line 44. if you are a nonresident alien, enter the amount from Form 104DNR, 5 line 42. Estates and trusts: Enter the amount from Form 1041, Schedule G, itne 1a, or the totai oi Form 990-T, I Caution: ifyou are cornpieting iine 20 for separate categorye (lump-sum distributions), see instructions. 21 Multiolarline 20 amount 01 WillEnter the smaller of line 14 or line 21. If this is the only Form 1116 you are filing, skip lines 23 through 27 and enter this amount on Fine 28. Otherwise, complete the appropriate tine in Part 22 3 4 0 2 . Part Summary of Credits From Separate Parts Ill 23 Credit tortaxes on passive category income 23 24 Credit 701' @133 .. 24 25 Credit for taxes on certain income re-sourced by treaty 25 26 2s 27 Add1ifiB523'fhr0Uoh25 27 28 Enterthe smauemurne zoornnezr 2e 3 . 402- 29 Reduction 0lJBFati0nS- 29 30 Subtract line 29 from tine 23. This is your foreign tax credit. Enter here and on Form 1040, line Formtoeown, line 45; Form 1041, Schedule e, line 23; or Form 990-T, line 211511 U1-10-13 Form 1118 (2012) - Information about Form 6251 and its separate instructions is at Department ol the Treasury Internal Revenue Service (99) Attach to Form 1040 or Form OMB No. 154 5-0074 Attachrneni sequence No. 32 Name(s) shown' on Form 1040 or Form BARACK H. a MICHELLE L. oesuzs. I Part I 'IA|ternative Minimum Taxable income Your social security number 1 If Schedule A (Form 1040), enter the amount from Form 1040, tine 41, and go to line 2. Otherwise, enter the amount from Form 1040, tine 38, and go to line 7. (If less than zero, enter as a negative amountMedical and dental. Enter the smaller of Schedule A (Form 1040), line 4, or 2.5% (.025) of Form 1040, line 38. if Zero or less. enter -0- .. 2 3 Taxes from schedule A(Form1o4or. line Enter the home mortgage interest adjustment, ii any, from line 6 of the worksheet in the instructions for this line 4 5 Misceilaneous deductions from Schedule A (Form 1040), line 27 5 5 Skip this line It is reserved for future use 6 7 Tax refund from Form 1040. tins 10 or line 21 7 3 investment interest expense (difference between regular tax and AW) 9 D3P"3ti?" bemeen arid 9 10 Netvoperating loss deduction from Fonn1040,llne 21. Enter as a positive amount 10 11 tex net operating toss doctocttoc 11 12 interest from specified private activity bonds exempt from the regular tax 12 13 Qualified small business stock of gain excluded under section 13 14 Exercise of incentive stock options (excess of AMT income over regular tax income} 14 15 Estates and (amount from Scheduie K-1 (Form 1041), box 12, code A) 15 16 Electing iarge partnerships (amount from Scheduie K-1 {Form 1065-B), box 6) 16 17 Disposition of property (diiferenoe between AMT and regulartax gain or loss) 17 18 Depreciation on assets placed in service after 1986 (difference between reguiar tax and AMT) 18 19 Passive activities (difference between AMT and regular tax income or loss) 19 20 Loss iimitations (difference between AMT and regular tax income or loss) 20 21 costs (dltteteece between teeutertsx and 21 22 Long-term contracts (difference between AMT and regular tax income) 22 23 Mining costs (difference between regulartax and 23 24 Research and experimental costs (difference between regulartax and AMT) 24 25 income from certain installment soles before January 7. 1937 .. 25 25 Intangible dntlirie costs preference 25 27 Other adjustments, inciuding income-based reiated adiustrnents 27 28 Alternative minimum taxable income. Combine lines 1 through (if married filing separately, see instructions|_Part 1| |A|ternative Minimum Tax (AMT) 29 Exemption. see instructions Subtract line 29 from line 28. if more than zero, go to tine 31. if zero or iess, enter -0- here and on lines 31. 33. and 35. and gore nnes4 as 400 554- 31 0 if you are filing Form 2555 or 2555-EZ, see instructions for the amount to enter. 't It you reported capital gain distributions directiy on Form 1040, line 13; you reported qualified dividends on Form 1040, tine Sb; or you had a gain on both lines 15 and 16 of Schedule 0 (Form 1040) (as refigured for the AMT, if necessary), complete Part on page 2 and enter the amount from line 54 hereAll others: if iine 30 is $175,000 or less ($87,500 or less if married tiling separateiy). multiply line 30 by 26% (.25). Otherwise, multiply line 80 by 28% (.28) and subtract $3,500 ($1,750 if married filing separateiy) from the result. 32 Aitemative minimum tax foreign tax credit (see instructionsTax from Form 1040, line 44 (minus any tax from Form 4972 and any foreign tax credit from Form 1040, line 47). If you used to figure your tax, the amount from line 44 of Form 1040 must be refigured without using AMT. Subtract line 34 from line 33. If zero or less, enter -0-. Enter here and on Form 1040, line LHA For Paperwork Reduction Act Notice, see your tax return instructions. 219481 12-12-12 Fon'n B251 (2012) Form 6251 1201 2) Usingmaximum Capital Gains Ftates. BARACK H. 8: MICHELLE L. OBAMA Complete Part oniy if you are required to do so by line or by the Foreign Earned income Tax Worksh Page 2 eet in the instructionsEnter the amount from Form 6251. tine 30. If you are filing Form 2555 or 2555-E2, enter the amount from line 3 Of the Worksheet in the instmetions for line 31 .. 35 Enter the amount from line 6 of the Qualified Dividends and Capital Gain Tax Worksheet in the instructions for Form 1040, line 44, orthe amount from line 13 oi the Schedule Tax Worksheet in the instructions for Schedule 0 (Form 1040), whichever applies (as refigured tor the AMT, if necessary) (see instructions). If you are filing Form 2555 or 2555-EZ, see instructions for the amount to enter 37 Enter the amount from Schedule 0 (Form 1040), line 19 {as reftgured for the AMT, if necessary) (see instructions). If you are filing Form 2555 or 2555-EZ, 599 i"3trU?ti0"5 for the amount *0 Enter .. 33 If you did not complete a Schedule Tax Worksheet for the regular tax or the AMT, enter the amount from line Otherwise', add lines 37 and 38, and enter the smaller of that result or the amount from line 10 of the Schedule Tax Worksheet (as refigured for the AMT, if necessary). if you are Form 2555 or 2555-EZ, see instructions forthe amount to enter 39 Enter the smaller ef line 36 or line 39 40 Subtract line 40 item line 41 if line 41 is $175,000 or less ($87,500 or less if married filing separately), multiply line 41 by 26% (.26). Otherwise, multiply line 41 by 28% (.28) and subtract $3,500 ($1,750 if married filing separately) from the reeult Enter: 0 $70,700 if married filing iointiy or qualifying widow(er), 0 $35,350 if single or married filing separately, or 4-3 $47,350 if head of household. Enter the amount from line of the Ciuatitied Dividends and Capital Gain Tax Worksheet in the instructions tor Fon'n 1040, line 44, or the amount from line 14 of the Schedule Tax Worksheet in the instructions _for Schedule (Form 1040), whichever applies (as figured for the regular tax). if you did not complete either worksheet for the regular tax, enter -0- 44 Subtract line 44 from line 43. If zero or less, enter 45 Enter the Smaller 01' line 35 0? line 37 45 Enter the smaller of line 45 or line 46 47 Subtract line 47 from line 46 48 lirtuitiply line 48 by 15% hr 49 if line 38 is zero or blank, skip lines 50 and 51 and go to line 52. Otherwise, go to line 50. subtract fine 46 from line 40 .. i 50 i Multiply line 50 by 25% (-25) Ir 51 Add lines 42tine 36 is $175,000 or iess ($87,500 or less if married ftting separately}, multiply line 36 by 26% (.26). Otherwise, multiply line 36 by 23% and subtract $3,500 ($1,750 if married filing separately) from fhefesult 53 Enter the smaller of line 52 or tine 53 here and on line 31. if you are filing Fonn 2555 or do not enter this amount on Fine 31. instead, enter it on line 4 of the worksheet in the instructions for line 3'1 .. 54 219591 12-12-12 Form 6251 (2012) ALTERNATIVE MINIMUM TAX Foreign Tax Credit (individual,-Estate,or-Trust} -v - - Attach to Form 1040, 1041, or 990-T. OMB No. 1545-0121 #2 Department of the Treasury A339:-imam (99) "information about Form 1116 and its seoarate instructions is at tlrrarur fro 1 LR 19 Name ideritiffiing numbgr as shown on page 1 ct your tax return BARACK H. 8: MICHELLE L. OBAMA Use a separate Form 1116 for each category of income listed below. See Categories oi income in the instructions. check only one box on each Form 1115. Report ail amounts in US. dollars except where specified in Part ll beiow. a El Passive category/Income la General category income '3 Section 9D1(,i) income It I: Certain income re-sourced by treaty i:i Lump-sum distributions UNITED STATES Note: if you paid taxes to only one foreign country or U. S. possession, use column A in Part and line A in Part ll. ll foreign country or U. S. possession, use a separate column and line for each country or possession. Part I 1 Taxable Income or Lose From Sources Outside the United States (for Category Checked Above} you paid taxes tomore than one Foreign Country or U.S. Possession Totai A (Add cots. A, B, and 9 Enter the name of the foreign country or us. OTHER Possession COUNTRIES ta Gross income from sources within country shown above - and of the type checked above: 39,875. 13 39,875. to Check it line 1a'is compensation tor personal services as an empioyee, your total compensation from all sources is $250,000 or more, and you used an alternative basis to determine its source [see Instructions) I: Deductions and losses (Cam-on: See instructionsPro rata share oi other deductions not definitely related: a Certain itemized deductions or standard deduction Other deductions (attach statement) Add fines 3a and 3b Gross foreign source income 3 9 8 75 - Gross income from all sources Divide line as byline Mu|tie|sriine3cbr|ine3f 4 Pro rata share oi interest expense: a Home mortgage interest {use worksheet for Home Mortgage interest in the instructions) 2 5 3 9 . Uiherinieiesifixiifinse 5 Losses trom foreign SDUFCBS .. 6 Addi%nes2,3g,4a,4e,and5 10,341. 6 10,341. 7 Subtract tine from line 'la. Enter the result here and on line 15. page Part II I Foreign Taxes Paid or Accrued Foreign taxes paid or accrued (you mm In ioreign currency in its. doiiars check one . (1.) paid} Taxes withheld at source on: Taxes withhetd at source on: malggatgiieign 8 (1) Acauad taxes paid or taxes paid or accrued (add cols. in geggcefigg Dividends {rn) Interest acme" (0) sacrum lei interest accrued (03 through illAdd lines A through 0, column (3). Enter the total here and on line 9, page LHA For Paperwork Reduction Act Notice, see instructions. 211501 Oi~--2d~13 Forrn111B (2012) ALTERNATIVE MINIMUM TAX Form 1116 (2012) BARACK . Sc MICHELLE . OBAMA Page 2 . 9 Enter the amount from line 8. These are ycurtotai foreign taxes paid or accrued for the category of income checked above Parii 9 3 4 2 . 10' Bareback or carryover {attach detailed computation) 10 11 Addiinessamsio 11 3.402. 12 Rsdustisninisreioniaxes 12 13 13 14 Combine tines 11, 12, and 13. This is the iotai amount 01 foreign taxes available tor credit 14 3 40 2 . 15 Enter the amount trorn line 7. This is your texabie income or {toss)1rom sources outside the United States (before adiustrnents) tor the category of income checked above Part Adjustments to line 15 16 1? Combine the amounts on tines 15 and 16. This is your net toreign source taxable income. {It the result is zero or iess, you have no toretgn tax credit for the category of income you checked above Part 1. Skip iines 13 through 22. Howeuer,i1you are filing more than 033 1115- 33% 29-) 18 Iridividoats: Enter the amount from Form 1040, tine 41, or Form tine 39. Estates and trustsfi Enteryour taxable income without the deduction for your - exemption Cautio e: if you figured your tax using the lower rates on quaiified dividends or capital gains, see instructions. 19 Divide line 17 by line 18. it line 1? is more than tine 18, enter 29,534. 20 individuals: Enter the amount from Form 1040, line 44. it you are a nonresident alien, -enter arnounttrorn tine 42. Estates and trusts: Enter the amount from Form 1041, Schedule G, tine 1a, or the total of Form 990-T, EInes3Send3? 2o 108 . 585 - Caution: if you are completing fine 20 for separate categorye {lump-sum distributions), see instructions. . 21 Multiptyline 20by|tne19(maxirnum amount otcreditEnter the smaller of line 14 or tine 21. it this is the only Form 1118 amount on fine 28. Otherwise, complete the appropriate line in Part IV 22 3 4 U2 . Part Summary of Credits From Separate Parts 111" 23 23 24 24 25 131535 09 0353'" 1009013 T9'50Ui93d 25 26 distributions 26 27 Add|ines23ihrsuoh26 27 28 28 3 . 402. 29 operations .. 29 30 Subtract tine 29 from line 23. This is your foreign tax credit. Enter here and on Form 1041}, tine Form 104oce, line 45; Form 1041, Schedute o, tine 2a; or Form eeo-T, line 40a so 3 4 2 . Forro111o(2o12) 227931 Form 1116 U.S. and Foreign Source Income Summary .. . - BARACK H. 8.: MICHELLE L. OBAMA - FOREIGN ENCOME TYPE TOTAL U.S. GENERAL Compensation 394,840. 394,840. Dividendsmistributions 2 . 2 . interest 11,462. 11,462. Capitai Gains Rent/Royaity stateitocai Refunds Partnersilipfs Corporation Trust/Estate Otherlncome --39,875. 39,875. 680,678. 640,803. 39,875. Less: Section 911 Exclusion Capital Losses 3,535- 3,635 - Capital Gains Tax Adjustment 677,043. 637,168. 39,875. Deductions: Expenses Rent/Royatty Expenses Partnershipls Corporation Losses Trustfiistate Losses Capitat Losses Non-capitai Losses Individual Retirement Account Moving Expenses Serf-employmenflex Deduction Salt-employment Health Insurance . Keogh Contributions Alimony Forfeited Interest Foreign Housing Deduction Utherfitdiustrnents 'Capitai Gains Tax Adjustment Totaioeductions 68,432. 60,730. 7,702. Aojustederossincome 503.<<511- 575.438>> 32.173- Less Itemized Deductions: Specifically Atioceied Homehiongagelnterest 45,046. 42,407. 2,639. Other Interest 63,305. 59,597: 3,708- Totel Adjustments to Adjusted Gross income Taxable Income Before Exemptions 350 226 . 324 400 . 25 826 . l't'?fi'Ii'i?'d'DEHflEtiDn5' NAME BARACK . Sc MICHELLE . OBAMA Toiaf itemized Deductions Form 1116 Itemized After Sec. 68 Deductions Reduction Specificauy U3. Specmcauy Foreign Ratabja Taxes Interest - Not Including investment interest 45,045. - 42,407. 2,639. Contributions Misceilaneous Deductions Subie-st to 2% .. Diher Miscelianeous Deductions Not including Bamhiing Losses Fc-reionsdiustment Total Itemized Deductions Suhlectto SecAdd itemized Deductions Not Subjectto Sec. 68: Ivietiicaifflentai .. |nV9Sim9fli .. Casuaity Losses Garnbiino Losses Foreign Adiustmont Total Itemized Deductions 2 5 8 3 8 . Totazmlowedonscheduies 192,441. 2,639. 63,305. 22?B?'i 95-01-12 Form1116 Foreign Tax Credit Carryover Statement [Page 1 of 2) NAME H. S: MICHELLE L. OBAMA Foreignlneomecategory FBENERAL LIMITATION INCOME . Regular 2010 2011 2012 1. Foreign tax paid/accrued - 2. FTC carryback to 2012 for amended returns 3. Reduction allocated to excluded income 4. Foreign tax avallabie 5. Maximum credit allowable Unused foreign tax or excess of limit -) Foreign tax carryback Foreign tax carryiorward Less treaty adjustment Foreign tax or excess limiiremainlng Total foreign taxes trom all available years to be carried to next year I nu-L c: 50 ~4 2002 1. 'foreign tax paidfacorued 2. oarryback to 2012 for amended returns 3. Reduction allocated to excludedincome 4. Foreign tax available Maximum credit allowabie Unused foreign tax Orexcessoflimitl-i Foreien tax Bareback .. Foreign lax carryiorward .. Less treaty adiustmeni Foreign tax or excess limilremaininu 01 -u 227915 D5-D1--12 NAME Form 1116 Foreign Tax Credit Carryover Statement (Page 2 of 2) BARACK H. 8: MICHELLE L. OBAMA Foreign income category GENERAL LIMITATION INCOME 2010 2011 1. Foreign tax paidlaccrued 2. FTC carryback io 2012 for amended returns 3. Reduciion allocated to exoiudeci income 4. Foreign tax availabie Maximum credit allowable Unused foreigniax or excess of limit 4) Foreign fax carryback Foreign tax carryionraard Less treaty adjustment Foreign tax or excees limit remaining Tviaiforeiontaxesirom aliavaifableyearsln be carried to nexivear Inn': 2002 1. Foreign tax paid/accrued 2. FTC carrybackto 2012 for amended returns 3. Reduction eilocated to Bxciuded income 4. Foreignraxavailable Maximum Unused foreign tax{ 0? 0f"mi1(- Tax iees treaiy adiusiment Foreign tax or excess iimifremainino 22?9"i6 BARACK H. MICHELLE L. OBAMA WLSTATEMENT LEUKEMIA SOCIETY ROAM 1040" RACES fiECfiiVEfi AND FEDERAL STATE AMOUNT TAX TAX SDI PICA MEDICARE NAME PAID WITHHELD WITHHELD TAX TAX TAX DIRECTORATE 394,840. 99,514. 18,942. 4,524. 5,725. TOTALS 394,840. 99,514. 10,942. 4,524. 5,725. SCHEDULE A STATE AND LOCAL INCOME TAXES STATEMENT 2 DESCRIPTION AMOUNT DIRECTORATE 19,942. ILLINOIS 2ND QTR ESTIMATE PAYMENTS 3,000. ILLINOIS 3RD QTR ESTIMATE PAYMENTS 3,000. ILLINOIS 4TH OTR ESTIMATE PAYMENTS 5,000. ILLINOIS PRIOR YEAR ESTIMATE PAYMENTS 5,000. ILLINOIS PRIOR YEAR BALANCE DUE AND EXTENSION PAYMENTS 512. TOTAL TO SCHEDULE A, LINE 5 35,554. SCHEDULE A CASE CONTRIBUTIONS STATEMENT 3 AMOUNT AMOUNT DESCRIPTION 50% LIMIT 30% LIMIT CANCER SOCIETY 100. AMERICAN RED CROSS 3,000. BOYS GIRLS CLUE 2,000. CALVARY SHELTER 1,000. CARE 1,000. CENTRAL ILLINOIS FOOD BANK 1,000. NATIONAL MEDICAL CENTER 2,053. CITIZENS UNITED FOR RESEARCH IN EPILEPSY 2,000. FISHER HOUSE POUNDATION 103,871. HABITAT POR HUMANITY 2,000. ILLINOIS HEAD START ASSOCIATION 1,000. ILLINOIS READING COUNCIL 1,000. JUVENILE DIABETES RESEARCH POUNDATION 1,000. 1,000. 1, 2, 3 BARACK H. MICHELLE LI OBAMA MASTERPIECES MIDTOWN EDUCATIONAL FOUNDATION 1,000. KITCHEN 1,000. .MOSAIC YOUTH THEATRE OF DETROIT 1,000. MUJERES LATINAS EN ACCION 1,000. NATIONAL AIDS FUND 1,000. NATIONAL COALITION FOR HOMELESS VETERANS 1,000. CONGRESS OF BLACK WOMEN 1,000. NATIONAL MS SOCIETY 1,000. NATIONAL OVARIAN CANCER COALITION 1,000. PALM BEACH COUNTY LAW ENFORCEMENT 5,000. ROCHELLE LEE FUND BOUNDLESS READERS 1,000. ST. CHURCH 1,000. ST. RESIDENCE FOR VETERANS 1,000. SIDWELL FRIENDS SCHOOL 5,000. THE CHRISTOPHER HOUSE 1,000. THE HARMONY PROJECT 1,000. UNITED NEGRO COLLEGE FUND 2,000. UNIVERSITY OF HAWAII FOUNDATION - 1,000. SUBTOTALS 150,034. TOTAL TO SCHEDULE A, LINE 16 150,034. SCHEDULE OTHER INCOME STATEMENT 4 DESCRIPTION AMOUNT DYSTEL GODERICH 110,461. RANDOM HOUSE 162,789. COPYRIGHT CLEARANCE CENTER 489. TOTAL TO SCHEDULE C, LINE 6 273,739. 3, 4 BARACK H. MICHELLE L. OBAMA Toss emyama 5 I I 1. ENTER THE AMOUNT FROM FORM 1040, LINE 350,225. 2. ENTER THE LOSS FROM SCHEDULE D, LINE 21, AS A POSITIVE AMOUNT. 3,000. COMBINE LINES 1 AND 2. IF ZERO OR LESS, ENTER . . . . . . 353,225. 4. ENTER THE SMALLER OF LINE 2 OR LINE 3,000. 5. ENTER THE LOSS FROM SCHEDULE D, LINE 7, AS A POSITIVE AMOUNT 5. ENTER THE GAIN, IF ANY, FROM SCHEDULE ADD LINES SHORT--TERM CAPITAL LOSS CARRYOVER TO NEX YEAR. SUBTRACT LINE 7 FROM LINE 5. IF ZERO OR LESS, ENTER . . 9. ENTER THE SCHEDULE D, LINE 15, AS A POSITIVE AMOUNT. 115,515. 10. ENTER THE GAIN, IF ANY, FROM SCHEDULE ll. SUBTRACT LINE 5 FROM LINE 4. IF ZER OR LESS3,00013. LONG--TERM CAPITAL LOSS CARRYOVER TO NEXT YE . SUBTRACT LINE 12 FROM LINE 9. IF ZERO OR LESS, ENTER . . 112,515. SCHEDULE SE NON-FARM INCOME STATEMENT 5 DESCRIPTION AMOUNT AUTHOR 258,772. TOTAL TO SCHEDULE SE, LINE 2 258,772. FORM 1115 EXPENSES DIRECTLY ALLOCABLE TO FOREIGN INCOME STATEMENT 7 DESCRIPTION COUNTRY AMOUNT OTHER EXPENSES DIRECTLY ALLOCATED OTHER COUNTRIES 7,702. TOTAL TO FORM 1115, PART I, LINE 2 7,702. 5, 5, 7 BARACK H. MICHELLE L. OBAMA 1 ENTER: $50,600 IF SINGLE OR HEAD OF $78,750 IF MARRIED FILING JOINTLY OR QUALIFYING $39,375 IF MARRIED FILING SEPARATELY78,750. 2 ENTER YOUR ALTERNATIVE MINIMUM TAXABLE INCOME (AMTI) FORM 6251, LINE 413,531. 3 ENTER: $112,500 IF SINGLE OR HEAD OF $150,000 IF-MARRIED FILING JOINTLY OR QUALIFYING $75,000 IF MARRIED FILING SEPARATELY . . . . . . . . . . . . . . 150,000. 4 SUBTRACT LINE 3 FROM LINE 2. IF ZERO oa LESS MULTIPLY LINE 4 BY 25% (.2555,033. 6 SUBTRACT LINE 5 FROM LINE 1. IF ZER0.0R LESS, ENTER -0-. IF ANY OF THE THREE CONDITIONS UNDER CERTAIN CHILDREN UNDER AGE 24 APPLY TO YOU, COMPLETE LINES 7 THROUGH 10. OTHERWISE, STOP HERE AND ENTER THIS AMOUNT ON FORM 6251, 0 LINE 29, AND GO TO FORM 6251, LINE 12,867. MINIMUM EXEMPTION AMOUNT FOR CERTAIN CHILDREN UNDER AGE 24. . ENTER YOUR EARNED INCOME, IF ANYENTER THE SMALLER OF LINE 6 OR LINE 9 HERE AND ON FORM 6251, LINE 29, AND GO TO FORM 6251, LINE .5 . . . tax.iliinois.gov lliinois Department of Revenue individual Income Tax Retum or for fiscal year ending Do not wme above this tine. Step 1: Personal Information BARACK . OBAMA MICHELLE . OBAMA 3. 5 0 0 AVENUE NW WASHINGTON, DC 20500 Fliing status (see instructions) Singie or head of househoid Married filing jointly l:l Martied separately l:l Widowed Check if same-sex civil union return (see instructions) St?p 2: 1 Fedora? adiusted gross income from your U.S. 1040, Line 37', US. 1040A, Line 21; or (whose dollars mm income U.S. Line Federally tax-exempt interest and dividend income from your U.8. 1040 or 1040A, Line 8b; or US. 2 .00 3 other additions. Attach Schedule M. 3 .00 4 Totai income. Add Lines 1 through .00 Step 33 5 Sociai Security benefits and certain retirement ptan income 3356 received if included in Line 1. Attach Page 1 of federal return. 5 .00 in income _6 illinois Income Tax overpayment Included in U.S. 1040, Line 10. 5 .00 7 Other subtractions. Attach Schedule M. 7 1 1 4 3 .00 Check if Line 7 inciudes any amount from Schedule 1299-C. El *5 :8 Add Lines 5, 6, and 7. This is the total of your subtractionsIllinois base income. Subtract Line 8 from Line Step 43 10 a Number of exemptions from your iederal return. $2,050 a 3 r" 20 3 .00 Exemptions If someone can cisim you as a dependent, see instructions. $2,050 .00 8 Check if 65 or older'. I: You Cl Spouse $1,000 0 .00 :21. Check if iegally blind: You l:l Spouse $1,000 .00 55 Exemption allowance. Add Lines a through d. 10 8 I 2 0 .00 Step 5: 11 Res,-de,,ts; Net income. Subtract Line 10 from Line 9. Skip Line 12Nonresidents and part-year residents: Income Check the box that applies to you during 2012 I: Nonresident l:l Part-year resident, and write the Illinois base income from sch. NFL Attach sch. NR. 12 - .00 A Step 5: 13 _;qe3;denf5_- Muftlpiy Line 11 by 5% (.05). 2 Tax Ngnresgdengs and parf..year Write the tax from Schedule NRFiecapture of investment tax credits. Attach Scheciuie 4255. 14 .00 15 Income tax. Add Lines 13 and 14. Cannot be less than zeroStep 77- 16 Income tax paid to another state white an Illinois resident. Tax After Attach Schedule CRProperty tax and K-12 education expense credit amount from refundable Schedule ECFL Attach Schedule ICR. 17 .00 2 Credits 1 8 Credit amount from Soheduie 1299-c. Attach Schedule 12090. 18 .00 3 19 Add Lines 1e, 17, and 18. This is the totai of your credits. Cannot exceed the tax amount on Una 15. 19 .00 20 Tax after nonrefundable credits. subtract Line 19'from Line 15.00 IL-1040 page 1 [Ft-12112) 249001 ID: 0105- 13 This form is authorized as outiined under the Iillnols Income 'fax Act. Disclosure cl this Information is required. Failure to provide information 0003:! result In a penalty. 21 Tax after nonrefundable credits from Page 1. Line 20.00 Step 8: tax. See instructions. 22' - - er Taxes 23 Use tax on Internet, maii order, or other out-of-state purchases from UT Worksheet or UT Table in the instructions. Do not leave blank. 23 0 .00 24 Total Tax. Add Lines 21.00 Step 9: 25 Illinois Income Tax withheld. Attach W-2.and 1099 forms.00 Payments 26 Estimated payments from Forms IL-1 040-58 and and including overpayment appiied from 2011 return.00 Refundable 27 Pass-through entity tax payments. Attach Scheduie K-1 --P or 27 .00 Credit 28 Earned Income Credit from Schedule IQH. Attach Schedute EGFI. 23 .00 29 Total payments and refundable credit. Add Lines 25 through 23.00 31599 103 30 Overpayment. If Line 29 is greater than Line 24, subtract Line 24 from Line 29. 30 4 9 2 .00 Result 31 Underpayment. if Line 24 is greater than Line 29, subtract Line 29 from Line 24. 31 .00 Step 1 1 1 32 Latepayrnent penalty for underpayment of estimated tax. 32 .00 . Underp ayment a Check if at least two-thirds of your federal gross income is from farming. I of Estimated Check if you or your spouse are 65 or cider and pennanentty Tax Penalty living in a nursing home. 1:1 and Donations Check if your income was not received eveniy during the year and you annualized your income on Form IL-2210. Attach Form IL-2210. :3 Check if you were not required to file an Illinois individual income Tax return In the previous tax' year. 1:1 33 Voluntary charitable donations. Attach Scheduie G. 33 .00 34 Totai penalty and donations. Add Lines 32 and 33. 34 .00 Step 12: 35 you have an overpayment on Line 30 and this amount is greater than Refund or Line 34. subtract Line 34 from Line 30. This is your remaining overpayment. 35 4 9 2 .00 Amount You 36 Amount from Line 35 you want refunded to you. If you want to deposit your refund directly Owe I into your checking or savings account, complete the direct deposit Information on Line 37. 36 0 .00 37 Cornpiete to direct deposit your refund Routing number Checking or 1:1 Savings Account number . 33 Subtract Line 36 from Line 35. This amount wilt be applied to your 2013 estimated taxyou have an underpayment on Line 31, add Lines 31 and 34. or if you have an overpayment on Line 30 and this amount is less than Line 34, subtract l_lne 30 from Line 34. This is the amount you owe. 39 . .00 Step 13: 'my, I state that i have examined this retum. and, to the best of my knowledge, it is true, correct, and complete. Sign and Data 1 glzoo EQ3 Your signature Date phone number Your spoI.Ise'5 signature [3313 ceaw??z 11/ 3/1' 5 Paid praparar'e signature Date Preparers phone number Preparers Sstii, or P11N I 111 Check, and complete beiow, to aliovv another person to discuss this return with the llilnois Department of Revenue. MICHAEL SOLHEIM We no longer automatically rnali 1099-G forms. Instead, we ask that you get this Information from our website. on Check the box if you still want us to rnaii you a paper Form 10996 next year. if payment enclosed, mail to: ILLINOIS DEPARTMENT OF REVENUE SPRINGFIELD 11. 6326-0001 . lino paymentenclosed, maiito: I ILLINOIS EIEPARTMENT OF REVENUE PO BOX 1040 GALESBURG ll. 61402-1040 249002 D1-03-13 ID: ZBX lL~1D4o page 2 [Fi~12l'l2) DR AP RR DC Illinois Department of Revenue .0ther-Additions and Subtractions Attach to your Form IL-1040 iL Attachment No. 15 Read this information first Compiete this schedule if you are required to add certain income on Form 040, Line 3, or if you are entitied to take subtractions on Form iL-'i 040. Line 7. it you are required to complete Schedule 'i299-C, Schedule F, or Form IL-4562, you must do so before you ccmpiete this schedule. Step 1: Provide the following information BARACK H. 8: MICHELLE L. OBAMA Your name as shown on Form ii.-1040. Step 2: Figure your additions for Form iL~1040, Line 3 Your Soclai Security number. Write the amount of {Whole dollars only) 1 Your'chiid's federaiiy taxexempt interest and dividend income as reported on U.S. Form 8814 1 .00 2 Distributive share of additions you received from a partnership, corporation, trust, or estate. Attach Schedule K-1-P or Scheduie K-1 2 .00 3 Lloyds plan of operations ioss, If reported on your behalf on Fon'n ii.-1023-C and included in your adiusted gross income - 3 .00 4 Eamings distdbuted from lFiC Section 529 coliege savings and tuition programs if not inciuded in your adjusted gross income {Do not include distributions from "Bright Start." "Bright Directions," or "College Illinois" programs or programs that meet certain disciosure requirements - see instructions.) 4 .00 5 Illinois special depreciation addition amount from Form iL-4562, Step 2, Line 4. Attach Form ii.-4562.' 5 .oo 5 Business expense recapture (nonresiclents only) 6 .00 7 Recapture of deductions for contributions to coiiege savings plans transferred to an out-of-state plan 7 .00 8 Credit taken on Schedule 1299-0 for student-assistance contributions you made as an ernpioyer 3 .00 9 Recapture of deductions for contributions to college savings pians withdrawn for expenses or refunded i 9 .00 'i0 Other income - identify each item 10 .00 1 1 Total Additions. Add Lines 1 through 10. Write the amount here and on Form lL~1040, Line 3. 11 .00 Step 3: Figure -your subtractions for Form IL-1 040, Line 7 Write the amount of 'l 2 Contributions made to the foilowing college savings plans: a "Bright Start" College Savings Pool 12a .00 "College |i?inois' Prepaid Tuition Program 121) .00 0 "Bright Directions" College Savings Pool 126 .00 13 Distributive share of subtractions from a partnership, corporation, trust, or estate. {Do not include any amounts contained in Lines 20 or 22 of this schedule.) Attach Illinois Schedule or identifying you as the partner. shareholder, or beneficiary and listing your Social Security number. - 13 .00 14 Restoration of amounts heid under claim of right under internal Revenue Code, Section 1341 14 .00 15 Contributions to a job training project 15 .00 16 Expenses reiated to iederai credits or federally tax-exempt income 16 .00 17 interest earned on investments through the Home Ownership Made Easy Program 17 .00 13 special depreciation subtraction amount from Form IL-4562, Step 3, Line 10. Attach Form lL-4562. 13 30 Write the foliowing oniy if included in Form iL-'i 040, Lines 1, 2, or 3: 19 Military pay earned. Attach military W2. 19 .00 20 U.S. Treasury bonds, notes. savings bonds, and U.S. agency interest from U.S. 1040A or1040. Attach a copy of us. 1040A or 1040, Scheduie B, if required federally. SEE STATEMENT August 1, 1969, valuation limitation amount from your Scheduie F, Line Attach Schedule and required federal forms. 21 .00 22 Enterprise or river edge redeveiopment zone and high impact business dividend subtraction amount from your Schedule Step 2, Line 10. Attach Schedule 1299-0. 22 .00 23 Add Lines 12a through 22 and write the amount here and on Page 2, Line 24Scheduie in page 1 in-12:12) 249061 owe-is ii): Step 3: Continued 24 Write the amount from Page 1, Line 23Recovery of items previously deducted on Us. 1040, Schedule A (including refunds of any state and local income taxes, other than Attach a copy of U.S. 1040, Page 1, and required federal forms. 25, .00 25 Flldesharing money and other benefits 25 .00 27 Payment of life insurance, endowment, or annuity benefits received 27 .00 28 Lloyds plan of operations Income if reported on your behalf on Form 023-0 28 .00 29 income earned by certain trust accounts established under the Illinois Pre-Need Cemetery Saies Act 29 .00 30 Education loan repayments made for primary care physicians who agree to practice in designated shortage areas under the Family Practice Residency Act 30 .00 31 Reparations or other amounts received as a victim of persecution by Nazi Germany 31 .00 32 interest on the following tax-exempt obiigations of Illinois state and local government. Do not include interest you received inciirectiy through owning shares in a mutual fund. a Illinois Housing Development Authority bonds and notes (except housing-related commercial facilities bonds and notes) 323 .00 Export Development Act of 1983 bonds 32b .00 Illinois Development Finance Authority bonds. notes, and other obligations [venture fund and infrastructure bonds only) 320 .00 Quad Cities Flegionai Economic Development Authority bonds and notes (if declared to be exempt from taxation by the Authority) 32d .00 College Savings bonds 329 .00 Sports Authority bonds 32f .00 9 High er Education Student Assistance Act bonds 329 .00 Development Finance Authority bonds issued under the Illinois Development Finance Authority Act, Sections 7.30 through ?.e7 32h .00 i Fiural Bond Bank Act bonds and notes 32) .00 Illinois Development Finance Authority bonds issued under the Asbestos Abatement Finance Act 32} .00 Quad Cities interstate Metropoiltan Authority bonds 32k .00 I Southwestern Illinois Development Authority bonds 32! .00 Finance Authority bonds issued under the Finance Authority Act, Sections 320.50 and 825.55 or the Asbestos Abatement Finance Act 3201 .00 Illinois Power Agency bonds issu ed by the lliinois Finance Authority 3211 .00 Central lilinois Economic Development Authority bonds 320 .00 Eastern Illinois Economic Development Authority bonds 3213 .00 Southeastern Illinois Economic Development Authority bonds .00 Southern Illinois Economic Development Authority bonds 32!' .00 ililnois Urban Development Authority bonds 325 .00 Downstate Illinois Sports Authority bonds 32t .00 Westem Illinois Economic Development Authority bonds 32u .00 Upper Illinois River Valley Development Authority Act bonds 32V .00 Will-Kankakee Fleglonai Development Authority bonds 32w .00 33 Interest on the following non-U.S. government bonds. a Bonds issued by the government of Guam 333 .00 Bonds issued by the government of Puerto Rico 33b .00 Bonds issued by the government of the Virgin Islands 330 .00 Bonds issued by the government of American Samoa 33d .00 Bonds issued by the government of the Northern Mariana lsiands 336 .00 Mutual mortgage insurance fund bonds 331' .00 34 Amount of your chitd's interest from U.S. Treasury and U.S. agency obligations or from sources in Line 20. 32 or 33 as reported on lJ.8. Form 3814 34 .00 35 Railroad sick pay and unemployment income. Attach Form and" a copy of your federai return. 35 .00 35 Unjust irnprisonrnent compensation awarded by Illinois Court of Claims 35 .00 37 Distributions from "Bright Start," "College and 'Bright Directions" college savings plans if included in Line 1 because you claimed a federai American Opportunity or Lifetime Learning Credit 37 .00 33 Total Subtractions. Add Lines 24 through 37. Write the amount here and on Form IL-1040, Line .00 Schedule page 2 (R-12112) 249052 is au ortze as ou me er a more ncorne as. use cs reo ID: 28X this information is required. Failure to provide information couid result in a penalty. Department of Revenue -..-20I1.2--. Computation of.Penalties for 0 -. Attach to your iL~ 1040 IL Attachment No. 19 Read t-hi3 information fir3t" We encourage you to iet us iigure your penalties and send you a bill instead of completing this term yourself. We wilt waive the late payment penalty for underpayment of estimated tax it you timely paid the lesser of too percent of the prior year's tax liability or 90 percent at the current year's tax liability. It you elect to oompiete Form it.-2210, this term reiteots that waiver. . For original returns only. Do not use this torm it you are filing Form Amended individual income Tax Return, after the extended due date of the return. Ste 1: Provide the followinmformation a CK H. -e MICHELLE L. oe Your name as shown on Form IL-1040 Your Sociat Security number Note: it your prior year tax return was filed using a different Social Security number than the number above, write that number here. . Step 2. Figure your required installments Thiseyear Lastfiyear 1 Write the amount of your total income tax from each tax return. See instructionsWrite the amount of credits from each tax return. See instructions. 2 3 Subtractt_ine2frornLine1. 3 29.450. 33.553- 43 Write the total amount of this year's Illinois withholding from your W-2 forms4-b Write the total amount of any pass-through entity payments made on your behalf. 4b 4G Add Lines 4a and 4b and write the result hereSubtract Line 4c from Line Muttiply Goiurnn A, Line 3, by 90% (.9Line 5 is $500 or less or if you are not required to make estimated tax payments, write and go to Step 3. Otherwise, write the lesser of Column A, Line 6, orcoturnn El, Line 3. 7 25 505 3 Divide the amount written on Line 7 by tour. This is the amount of each required installment. (It you use the annualized income instaltment method, see instructionsQuarter 1 Quarter 2 Quarter .3 Quarter 4 15th day oi 4th 15th day of 6th 15th day of9ti1 15th day of 1st mo. 93 Write the installment due date for each month of tax year month of tax year month of tax year after end of tax year quarter.Seeinstructions. . - 09/17/12 01/15/13 9b Write the required installment. 4,584: 7,436: 6,484. 8,001: 10a Write any credit carried forward trorn the prior year. Skip this line tor Quarter 2. Skip this line tor Quarter 3. Skip this line tor Quarter 4. 10b Writethearnountoftaxwithheid. 4.735- 4,736. 4,736. 4,734. 1 00 Write the amount of pass-through payments. 10d 4,736. 4,736. 4,736. 4,734. 11 Subtract Line 10d from Line 9b. if the - arnountis negative,use brackets. 2:700 - 1 748 - 3 267- 12 if the amount on Line of the previous quarter is negative. write that amount as a positive here. Otherwise, write Skip this itnetor Quarter Subtract Line 12 from Line 11. the - amountls negative,use brackets. <152o> 2,548. 1,748. 3,267- Continue with Step 3 on Page 2 this form is authorized as outlined under the iltlnois income Ta): Act. Dlsciosure of th is Information is required. Faliure to provide information couid resuit In a psnaity. 249101 o1-es-13 IL-2210 ts-1212) ID: Page 1:314 Wfiteeu 3= ..Eiss.re . 14 Write the amount from Column A, Line Write the amount of household employment tax from IL-1040, Line 22. 15 1 5 Write the amount of use tax from IL-1040, Line 23. 15 17 Add Lines 14 through 'i6. Write the totai amount hereWrite the total amount of all payments made on or before the original due date of your tax return. include any credit carried forward from the prior year, your total estimated payments made this year, Form payments, the pass-through entity 2: ments made on your behalf, and your withholding as shown on your W-2 forms. Compare that total to the tota Line Qb, Quarters 1 through 4, and write the greater amount hereSubtract Line 18 from Line 17. if the amount is 0 positive, write that amount here. Write this amount in Penaity Worksheet 2, Line 23, Column 0 and continue to Step 4. I 0 zero or negative, write that amount here and, if negative. use brackets. 19 <4 9 2 . Step 4: Figure your late--payment penalty Use Penalty Worksheet 1 to figure your Iatepayment penalty for underpayment of estimated tax. Use Penalty Worksheet 2 to figure your late-payment penaity for unpaid tax. You must follow the instructions in order to property comptete the penalty worksheets. 20 Write the amount and the date of each payment you made. See instructions. Amount Date paid Amount Date paid Amount Date paid a 3,000. 05/15/12 i 3,000. 09/17/12 5 5,000. 12/28/12 9 ci I Number of days late Penalty rate Penalty rates .02 310i -10 Penalty Worksheet 1 - Late-payment penalty for underpayment of estimated tax If you paid the required amount from Line '13 by the payment due date for each quarter, do notcornplete this worksheet. 21 Write the unpaid amounts from Line 13, Quarters 1 through 4, on the first line of the appropriate quarters in Column 0 beiow. A Due Unpaid Payment Balance due Payment Number Penalty rate Period date amount . applied date of days late {See above) Penaity onz 06/15/12 2,548. 2,548. 06/15/12 2,548. 3,000. -452. 06/15f12 one 09/17f12 1,748. 1,748. O9!l7/12 1,748. 452. 1,296. 1,296. 3,000. -1.704. 09/17/12 0&4 01715/13 3,267. 3,267. 01X15X13 3,267. 1,704. 1,563. O1/15fl3 1,563. 5,000. --3,437. 01f15X13 22 Add Column i, Quarters 'i through 4. This is your late-payment penalty for underpayment of estimated tax. Write the total amount here and on your Form Ii.-1040, Line 32 {round to whole dollars). 22 0 You may apply any remaining overpayment from Quarter 4, Column above to any underpayment when figuring Penalty Worksheet 2, only if the payment date in Column is after the original due date of the return. Page20f4 Penafty Worksheet 2 Late--payment penalty for unpaid tax 23 Write any positive amount from Line 19 on the first line of Column below. A Due Unpaid Payment Balance due Payment Number of Penalty rate Return date amount applied (Col. 0 -- Goi. D) date days iate (See above) I Penalty 24 Add Column I. This is your iate--payment penalty for unpaid tax. Write the total amount here and on Line 33. 24 Step 5: Figure your late-filing penalty and the amount you owe Figure your late-filing penaity only if you are ftiing your tax return after your extended due date, and your tax was not paid on or before your original due data. Figure your late-filing penalty. 25 Write the amount from Form IL-1040. Line 15. 25 25 Write the amount of househoid empioyment tax from Form IL-1040, Line 22. 26 27 Write the amount of use tax from Fomn il.-1040, Line 23. 27 23 Add Lines 25 through 27. Write the total amount here. 28 29 Write the totai amount of credits and payments made on or beiore your originai due date. 29 30 Subtract Line 29 from Line 28. 30 31 Multiply the amount on Line 30 by 2% 31 32 Write the lesser of Line 31 or $250. This is your penaity. 32 Figure the amount you owe. 33 Write any late-payment penaity for unpaid tax irom Line 24. 33 34 Write any penalty from Line 32. 34 35 it you have an overpayment on Form 040, Line 35, write that amount as a . if you have an amount due on Form IL-1040, Line 39, write that amount as a positive number. 35 35 Add Lines 33 through 35. If the re-suit is a negative number, this is the amount you are overpaid (before any amount appiled to next year's estimated tax}. if the result is a positive number, this is the amount you owe. See Form IL-1040, Line 39, instructions for your payment options. 36 Continue to Step 6 on Page 4, if annualizing your income. ID: EBX 249103 01-es-13 i'L--221iJ Page 3 oi :1 Step 6: Complete the annualization worksheet for Step 2, this {rirE|??heet was to annualize your income. Compiete Lines 37 through 53 of one column before going to the next, beginning with Column Write your Iliinois base income for each period. See instructions. Annualization factors. Multiply Line by Line 38. This is your annualized Income. Exemptions. See instructions. Subtract Line 40vfrorr1 Line 39. This is your net income. Multiply Line 41 by 5% (.05). For each period, write the amount you wrote on Step2, Line 2, Coiumn A. Subtract Line 43 from Line 42. Appiicable percentage.' Muitipiy Line 44 by Line 45. This is your annualized instaiiment. Add the amounts on Line 53 of each of the preceding coiumns and write the total here. Subtract Line 47 from Line 48. if iess than zero, write Write the amount you would have entered in Step 2, Line 9b, if you were not annualizing. Write the amount from Line 52 of the preceding column. Add Lines 49 and 50. if Line 51 is greater than Line 43, subtract Line 48 from Line 51. Otherwise, write Write the lesser of Line 48 or Line 51 here and on Step 2, Line 9b. This is your required installment. D: 213)! 249104 01-05-13 Page First 3 months First 5 months First 8 months Ail '12 months 103,927. 226,008. 370,990. 597,193. 4 2.4 1.5 1 415,708. 542,419. 556,485. 597,193. 8,200. 8,200. 8,200. 8,200. 407,508. 534,219. 548,285. 588,993. 20,375. 26,711. 27,414. 29,450. 20,375. 26,711. 27,414. 29,450. 22.5% (.225) 45% (.450) 67.5% (.675) 90% {.900} 4,584. 12,020. 18,504. 26,505. Skipthisllnaforcolumnlt. 4,584. 4,534. 7,435. 5,434. 3,001. 6,626. 6,626. 6,626. 6,627. Si